The pill and condoms

LoSEASONIQUE

The Photo: Pictured is of one of the newer extended cycle combined (estrogen/progestin) oral contraceptives that allow a woman to have only four pill-periods (withdrawal bleeds) a year. Under the LoSeasonique extended-cycle regimen, women take of 84 orange combination tablets containing 0.1 mg of the progestin levonorgestrel and 20 mcg of the estrogen ethinyl estradiol, and 7 yellow tablets containing 10 mcg of ethinyl estradiol. Levonorgestrel is one of the older and safer progestins, not nearly as likely to contribute to blood clots as etonogestrel (NuvaRing and Implanon) and drospirenone (Yaz and Yasmin) though the likelihood of severe side effects on etonogestrel or drospirenone is still very low. The problem with levonorgestrel is that it doesn’t have as long a half-life in the body as the newer progestins and therefore pills that use it are more sensitive to level fluctuations if not taken correctly.

I’m posting this because: This is the most thorough discussion I’ve found of things to consider and what a woman’s (or a couple’s) reasoning should be when deciding if ‘the pill’ offers enough protection for the woman, or if the couple should use condoms to provide added protection. I am having my Contemporary Sexual Health students at St Lucy’s bookmark this article on the Scarleteen site.

This article addresses things that impact the real-world effectiveness of birth control which Eric, a good friend and frequent reader, obliquely raised in a comment to my May 10, 2011 post ‘Effectiveness rates using 2 methods of birth control.’ He wrote: “I wonder if anyone would be willing to try putting these numbers into real-world practice?” Many women for whom 95% effectiveness isn’t good enough use condoms to improve their chances of avoiding pregnancy and condoms are a must when having sex with a partner whose sexual history is unknown.

Scarleteen.com
By Heather Corinna
May 6, 2011

If You Use the Pill, Do You Still Have to Use Condoms?

“Kori asks:

I'm and 18 years old and have been having sex for a year and been on the pill for about a year. I take my birth control like a ritual at the same time every day (the combination pill). Sometime my boyfriend and I don't use a condom in the beginning to get him hard then we always put one on. My question is, when on the pill do you absolutely have to use condoms? They say that every time you have sex you NEED to use a condom. I know it is the most effective way, but I thought that the one of the points of the pill is so you don't need to use a condom.

Heather Corinna replies:

We get asked about this a lot; about whether once you have a more effective method of contraception than condoms, like a hormonal method or IUD, if they're still needed to prevent pregnancy.

The only right answer to that question, no matter who asks it, is that it really depends on what you and your partner want and need.

All methods of contraception, including condoms, can prevent pregnancy, but some methods are more effective than others. If someone had to choose between condoms and the pill, and just wanted to choose one based ONLY on which was the more effective method of the two in preventing pregnancy when used properly, then they'd choose the pill, because it's more effective in both typical and perfect use. But that's not usually the only factor in people's decisions about contraception or condom use, and plenty of people don't have to choose just one.

If you want the most effective, foolproof protection you can get from unwanted pregnancy and still want to have the kinds of sex that present pregnancy risks, then you'll want to use dual protection: to use two methods, not just one, because using two is always more effective. If you're comfortable with or prefer less protection than two methods can offer, then it's okay to only use one method.

There are no have-to's here, there's just what you want to choose to do as an individual, based on what you want, feel most comfortable with and are or are not willing to take a given level of risk with. If you need a little help making that decision, I can certainly walk you through some of that process, and give you some information that might help inform your choices.

How effective at preventing pregnancy a given method is is often one of the biggest, if not the biggest, factors for people making these choices. So, let's have a look at that first. The combined birth control pill is over 99% effective in perfect use, and 92% effective with typical use (same goes for the ring and the patch). With the pill, specifically, some studies have found that typical use rate is substantially lower for young adults younger than 19, but it sounds like you do use your pill properly, and have for some time, so that probably doesn't apply to you.

What any of those percents mean in the real world is this: 92% in typical use means that for every 100 women who report the pill is the method of contraception they have used in one year, 8 of them became pregnant while using that method, and 92 of them did not.

My best advice when people are trying to figure out if they're in perfect or typical use is to remember that perfect use rates are usually from controlled clinical trials, and typical use rates reflect self-reporting and more typical, real-life use, which includes things like taking a pill late or even missing one now and then in a given year (which is very common: taking a pill at exactly the same time for one whole year, never missing any, never throwing one up, and so forth is pretty tough to pull off). To be safest, it's usually best to consider typical use rates when choosing a method or methods, especially with an ongoing method like the pill where how you take it every single day influences your risks, not just how you take it on the day you have sex, unlike with something like condoms, where how you use it only matters each time you use it. To be sure that's clear, how someone used condoms three days ago has no impact on how well using condoms today will protect them, whereas how someone used the pill three days ago IS relevant to possible risks with sex they have today.

But if you know you use your pill as properly as possible, and have swung that for a year of use to know you can do so for a full year, if you average the typical use rate and the perfect use rate, you probably have a good sense of what your effectiveness is. For the combined pill, that'd be 95%.

Once you know the numbers like that, the question to ask yourself is if that's okay with you. Are you comfortable with something around that 5% in-one-year chance of pregnancy? If you are, then it's okay for you, according to you, to use the pill alone when it comes to preventing pregnancy.

If you're still on the fence and want a comparison, let's do the same math once you add a condom. Condoms are 98% effective in perfect use and 85% effective in typical use. We show estimated rates for using combined methods of contraception here. [This information is found in my post ‘Effectiveness rates using 2 methods of birth control’]. On that page, you'll see the combined rate for perfect use of both methods is 99.99% effective the estimated combined rate of both methods used more typically is 98.8%. If we do that same averaging we did with the pill, for those who use condoms really well, that gives us a 91.5% effectiveness. For those who use both methods very well, then we're looking at just over 99%, a little more than a 4 percent difference between using the pill alone, and just about the same effectiveness as the pill by itself in the kind of perfect use found in a controlled study.

Again, in more practical terms, that means that for 100 people using both the pill and condoms really well over one year, that probably less than one will become pregnant as opposed to five with the pill alone or close to nine with condoms alone. In both cases, that's a pretty big difference.

How big or small a difference that seems to you, though, is going to be about you. There are people who don't want to become pregnant and want to try and prevent it, but who also feel like it would not be the hugest deal if they became pregnant. There are other people who earnestly feel the world would come to an end and to whom pregnancy seems like the worst thing that could happen to them at a given time. Sometimes during one time of life or relationship, while we don't feel a pregnancy would be ideal, we feel like it would be okay and that whatever choice we might make, we could deal with that choice. Other times, for whatever reason, it really is just the last thing we want to have happen. I'd say that if and when you're in the world-will-end, last-thing-I can-deal-with group, that if you're going to have the kinds of sex where pregnancy is a risk, dual contraception is the way to go. If a possible pregnancy feels way less dire than that, then it's much sounder to consider only using one method.

This is something you can also talk with your partner about. There are a few reasons why some couples prefer using condoms, specifically, with another method to prevent pregnancy. One of the biggest perks is that then both people get to share responsibility and both people also get to have some control over the prevention of pregnancy. While a pregnancy can't impact your partners' body and health as it would yours, and often asks less of them in terms of the impact on their whole life, it still can have a big impact on their lives, no matter what choice you make with it, particularly should you become pregnant and choose to parent.

Some folks feel fine without that personal control of their own, while it makes other people really uncomfortable. Some folks also react particularly badly to an unintended pregnancy when they didn't have control: it's easy to blame the other person who had it when it happens, even when a birth control failure wasn't that person's fault. I also don't know what your feelings are about taking all the responsibility for birth control here. If you would rather it be shared, that's one reason to keep using condoms, but you also have the option of sharing responsibility for the method you're using alone, too, like having a partner split the bill for it.

You also might want to consider how much you and/or your partner tend to worry about this stuff. Any kind of worry or anxiety can impact the quality of our sex life and our whole life, so if using one less method = more worry for either of you, that may not be so ideal. If, on the other hand, using two methods alleviates worries, it may be a real positive. And if it seems to make no difference, then maybe this just isn't a factor for either of you at all.

How much you and your partner like using a given method and what kind of access you have to that method is often another factor. So, if the pill alone doesn't leave you feeling secure enough, but using condoms is an issue for any number of reasons, you might also bear in mind the pill isn't your only option and there are more effective methods than the pill, and, since the main difference with those others is mostly with typical use, far more goof-proof ones.

You may have the option of choosing a method of contraception that's more foolproof and effective in typical use. Sometimes people use the pill just because it's the only method they knew about or the only one a healthcare provider suggested: I don't know if you've considered other methods or not. Depo-Provera injections, the contraceptive implant and IUDs all have much higher rates of effectiveness in typical use, because they're really, really hard to screw up as a user. With IUDs and implants, there's nothing you really need to do at all, save replacing them every five to ten years. With an injection, you only need to remember to go get a shot once every three months. So, if you want to ditch condoms, but in looking at all this, you feel like the pill isn't leaving you feeling secure enough, you can talk to your sexual/reproductive healthcare provider about some of these other, more effective, options. The healthcare provider you see for contraception is also always a great person to ask the questions you're asking me.

This also isn't a choice you have to make in any permanent way. You may find there are times in your life or relationships where you feel just fine using only one method, or this one method, and times when you feel a lot better backing your method up. And sometimes you may need to use a different method temporarily, like if you've got to or want to go off the pill for any reason or you did wind up missing pills or need to take a medication which may interact with the pill. So, don't feel like this is something you only get to decide once and have to stick to ever after: it's not. You can always change your mind based on any changes in your feelings or circumstances.

Last, but absolutely not least, one of the biggest differences between all other methods of contraception and condoms is that only condoms can reduce your risk of sexually transmitted infections.

Many young people immediately stop using condoms once they have another method of contraception, even if they haven't yet done all they need to to reduce their STI risks. For our readers at Scarleteen specifically, this is a pretty big deal since the age group with the highest rates of STIs are those in their teens and early 20s, with around one in every four people in that age group contracting an STI every year in the United States alone. The risks of STIs are pretty big at your age, and more often that not, it's the folks who worry least about them who tend to be the most at risk, since they also tend to be the folks who don't do enough, or anything, to reduce those risks, which includes using condoms and other barriers for any oral, vaginal and/or anal sex.

My best advice is always to figure that for as much as you're concerned about unwanted pregnancy, you want to be sure you're just as concerned about STIs, and doing just as much to prevent acquiring or transmitting infections as you are in trying to prevent pregnancy.

If you do want that extra protection, either from pregnancy, STIs or both, and your boyfriend is having issues with erection when condoms are on right from the start, know that practice with condoms usually does make perfect. If he gets used to having condoms on from start to finish, chances are that this won't stay an issue like it has been. Of course, you both also always have the option to spend more time before intercourse with sexual activities other than intercourse (or oral sex, if you want to reduce STI risks for that activity by using condoms with it) to get him, and you, more aroused before intercourse starts. You can also try different styles or brands of condoms, including the female condom, so that it's not even going on him at all. Just know that if you're going to use condoms, using them properly is very important, just like using your pill is. Proper use includes a condom being used from start to finish with sexual activities, not being put on or taken off halfway through.

Again, there are no have-to's here. There are just your personal choices, made either on your own -- you are the one who would potentially become pregnant, after all -- or with a partner. I think it's always wise to make these choices very carefully and with as much information as possible, and when it comes to preventing outcomes we don't want, we just want to be sure that whatever choices we do make really fit with what we most want, don't want, and what we do and don't all really feel ready to handle.”